Addressing the Tuberculosis epidemic with cloud and mobile technology

Bill Thies, senior researcher at Microsoft Research India. was recently named a MacArthur Fellow in part for his work on 99DOTS, a tuberculosis medication adherence initiative.

In a busy neighborhood in India, a young girl tries to keep up with her older sister on their way to the village school. Their classroom is some distance away, and the hurrying is hard for the young girl, named Manisha. Manisha’s mother’s biggest dream is for Manisha to stay in school. For the 9-year-old with the big eyes and quick smile, her heart’s secret wish is something even more urgent: to dance and run outside with her friends.

This simple childhood freedom and the long-term education her mother wants so badly for her could be permanently out of reach for Manisha. She has tuberculosis (TB), a bacterial illness that is now the world’s leading infectious disease. TB, which is airborne and contagious, kills more than one million people a year, and if governments and health-care workers are not able to clamp down on the disease there could be severe global consequences.

Like the millions who have TB, Manisha can treat her illness by taking a six-month course of antibiotics, drugs that are by and large easily available and affordable or even free. As long as health-care professionals can monitor her symptoms and progress with regular check-ins, and as long as she takes the full course of medication, the girl and patients like her could make a full recovery, moving on to cartwheels, farming, engineering studies, or whatever their dreams hold.

But if Manisha is like most of India’s 1.3 billion people who live on less than $3 a day, the journey to completing TB treatment is dotted with obstacles.

To be monitored properly for their treatment, “TB patients have to miss their home and work responsibilities; they have to travel long distances to treatment centers, stand in line with the stigma of the disease, and so on. Patients start feeling better after a few weeks, and it’s very hard to get them to continue the full course of treatment,” said Bill Thies, who has been working on TB with the Microsoft Research lab in India since 2008. Bill and his team have developed a game-changing treatment approach called 99DOTS that involves pill packets, data corralling, and simple cell phones.

In trying to fell a global killer, Bill, who has attacked the disease from several angles with multiple projects, has learned that sometimes the highest-impact solution is much more low-tech than you’d think.

‘No substitute for being there’

Bill first became engaged with TB treatment as a student participating in the 2007 MIT IDEAS competition and the Muhammad Yunus Innovation Challenge to Alleviate Poverty, where he worked on a low-cost electronic pillbox that aimed to monitor and improve medication adherence.

“Our first few times we tried to solve it, we didn’t succeed. We had several solutions that did not work in the field, and we had some special-purpose devices that didn’t scale up,” Bill said.

But those misses were important steps on the road to innovation. The obsession with improving TB treatment outcomes—and the broader calling to help those who are disconnected and suffering be empowered through technology—had its hooks in him.

“There is no reason that anyone should die from TB,” he said. “It is a completely curable disease.”

In 2008, Bill headed back to India to join the Bangalore lab of Microsoft Research on a team that now includes Program Manager Andrew Cross and Consulting Program Manager Nakull Gupta. As part of the Technologies for Emerging Markets group, he and his colleagues began to lay the foundation for the work that would eventually lead to 99DOTS.

When you need more than medicine

From the beginning, Bill’s team knew it couldn’t fight TB without partnering closely with care providers in the field, who knew firsthand the barriers to treatment.

First, Bill tackled the problem of lack of data. Many care providers were writing patients’ treatment records by hand, a system that the research team knew made it hard to track a complete picture of each patient’s health.

A patient in India logs medication with 99DOTS.

Working closely with Operation ASHA, India’s largest nongovernmental organization in TB treatment and prevention, the team developed a biometric monitoring system that enabled a care provider to use a fingerprint reader and netbook computer or smart phone to log patient data, including symptoms and medication doses, during a checkup.

Historically, TB has been controlled in part through the implementation of DOTS (Directly Observed Treatment/Therapy, Short-Course), which allows care providers to track a patient’s treatment by directly observing them take doses of their medicine. The method is very successful when patients are able to access care providers, and with Bill’s team’s biometric monitoring, the data collected was much more accurate.

But despite advancements, there were gaps.

“Where DOTS is feasible, that system monitors that records are kept accurately and that providers are motivated and rewarded for meeting with patients,” Bill said. “A rigorous study by economists from MIT, the World Bank, and elsewhere found that the system offered significant benefits. However, one thing we learned is that DOTS is very hard to implement completely. Due to travel and other constraints, some doses are inevitably unobserved, and we wanted to have more confidence that those drugs are taken.”

These gaps in treatment and monitoring can have major epidemiological impacts: a patient who doesn’t complete the course of treatment—and whose care provider doesn’t intervene because they’re not aware of the lapse—can develop drug-resistant TB.

“Drug resistance is 100 times more expensive to treat,” Bill said. “In fact, drug-resistant TB is a threat to every country around the world. And so what may seem like a very distant problem is actually right here, knocking on our door.”

If health-care providers were able to know that patients have lapsed in taking their medication, Andrew said, they could quickly get them back on track through an intervention. That’s where 99DOTS comes in.

A pill, a packet, a phone number, and a plan

In December 2013, Alain Labrique, a professor at John’s Hopkins who was looking at how increased availability of mobile phones could impact health-care access in middle- and low-income countries, raised the idea of patients sending a missed call to a fixed number whenever they took medication.

In India, the lightbulb went off. “We improved on that idea by keeping the number hidden behind the pills, similar to an SMS scheme we had thought through earlier,” Bill said. “Some credit definitely goes to Alain!” he immediately added.

The 99DOTS system works like this: Individual TB pills are packaged side by side in a blister pack. The blister packs are wrapped in a custom envelope, sealed by the care provider. When patients dispense their daily dosage, they punch through perforated flaps on the back of the envelope. Every day, they reveal a hidden phone number. Patients use their phone to place a call to this toll-free number, and a computer answers the phone, says thank you, and then hangs up.

If the patient is able to receive texts, the system can send reminders to take medication, though it’s not required to participate.

“With that simple interaction—the combination of the caller ID of the patient, which was registered at the beginning of treatment, and the sequence of phone numbers that they call throughout their course—we have very high confidence that the pills are actually in their hand,” Bill said. “99DOTS offers 99 percent of the benefits of DOTS at a small fraction of the inconvenience and cost to patients.”

Patients are empowered to take control of their treatment and are motivated to follow the protocol when they know their nurses and doctors are monitoring the data. And research has shown that if a patient has a pill in hand, it’s almost always taken.

“So long as they are making the phone calls, they are making their best effort to stay engaged with the provider and keep up with the treatment,” Andrew said. “This is known to be one of the best predictors of medication adherence and treatment success.”

With 99DOTS, patients can communicate to their care providers and be tracked without traveling to a clinic. And when patients across different regions stop taking the drugs early, the data, assembled in an analytics dashboard powered by Azure, shows the patterns of lapse. Providers can intervene where it’s needed most with targeted training sessions that have improved the adherence metrics.

“When I go to visit my village every weekend, my children are there, and I get caught up with them and forget to take my tablets,” said one patient in an interview about the system. “When the message [SMS from 99DOTS] arrives, and I see it on my phone, I remember that, ‘oh I have to take my tablets!’ It also sends a second reminder message. That is very useful.”

The program has grown steadily. Currently, the Indian government is using 99DOTS for every patient who is co-infected with TB and HIV—50,000 people per year spread across more than 500 treatment centers. It has also launched 99DOTS for every TB patient in Mumbai—one of the hot-spots of TB in India, with an expected load of 30,000 patients per year. The stories that have come in from the field are ones like this: a patient had stopped taking his TB medicine because he thought the side effects he was feeling were from the pill; once his health-care worker saw the trend of skipped doses and intervened, it was discovered that the side effects were actually symptoms of the TB, and the patient was able to get the information he needed to get back on track.

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